Required medical coverage at horse trials USEF vs FEI.... the US is lacking

[grzywinskia]

Someone posted a very good question in the Liz Halliday or AEC thread about the required medical coverage at USEA horse trials. I wanted to take some time to explain things as I know it.

Firstly some background, I am a previous 5* rider and current Nationally registered EMT- B (Basic). My husband is a former 4* level TD and organizer of national and FEI horse trials and he is a current nationally registered Paramedic. We are both practicing first responders and we own a non - emergency ambulance service.

Approximately 4 years ago, after a situation at an Area V event where a competitor suffered a compound wrist fracture and the “EMT” had no equipment and the nearest hospital was an hour by road, my husband and I both sat down thinking of what can be done to make the sport safer. He was a member of the USEA Organizers committee and I was a member of the USEA competitions and rules committee.

We looked at the requirements for medical personnel at events. As I stated, we were currently organizing events but we were adamant that regardless we would have sufficient ALS personnel and equipment rather than what is required. We were quite surprised to find out what the USEF requires.

Before I go further, in the original post, the poster asked the difference between a paramedic and an EMT. As she mentioned, it can vary state by state as do the protocols they must follow. Very briefly below is the VA standards just for some perspective

BLS (Basic Life Support) EMT- B (Basic)- Take vitals, administer prescribed epi- pens, administer oral glucose, apply c- collars, apply splints, transport, apply and use an AED, apply and relay a 12 lead EKG- in VA I can install a supraglottic airway (iGel)- apparently this is uncommon in other states

ALS (Advanced Life Support), Paramedic - start IVs, administer pain relief, interpret a 4 lead, INSTALL AIRWAYS (INTUBATE).

Here is the exact rule for USEF

1. Qualified medical personnel with no other duties and with appropriate medical equipment, as required by their certifying State or EMS Region, must be present during all scheduled performances at all competitions and during all paid scheduled schooling sessions over fences, including 1 day prior to the start of the competition, if applicable,
2. Qualified medical personnel is a currently certified or licensed EMT, or Paramedic, Certified First Responder, or a Physician or Nurse trained in pre-hospital trauma care and currently certified or licensed in their profession under applicable law where the competition is held. Exception, for eventing competitions the minimum requirement is an EMT/Paramedic who is pre-hospital trauma trained.
3. A Physician or Nurse trained in pre-hospital trauma care is a Physician or Nurse who is currently certified in Advanced Trauma Life Support (ATLS), Basic Trauma Life Support (BTLS), Pre-hospital Trauma Life Support (PHTLS), or who has First Responder or comparable certification.
4. It is strongly recommended that EMTs and/or Paramedics be used to fill this position. Medical personnel must not exceed the scope of their practice.
5. All medical personnel must be readily identifiable, available, and mobile.
6. Unless prohibited by Federal, State or local law, this person must furnish the Steward(s) or TD(s) with acopy of their report(s), or assist these officials with documenting any findings and treatment for all injuriessustained in competition or on the competition grounds.
7. An ambulance must be on the competition grounds or on call during all scheduled performances at allcompetitions and during all paid scheduled schooling sessions over fences, including 1 day prior to the startof the competition, if applicable. Exception: Endurance Competitions.
8. Required Number of Qualified Medical Personnel

a. Competitions using more than three performance areas simultaneously must have at least one additional person who is CPR-certified to assist the medical personnel of record for that competition. The additional person may have other duties related to the competition provided they can be immediately available to respond to an emergency. This person must be identified to officials and staff. Dressage arenas do not count as performance areas.

1. If more than six performance areas are used simultaneously there must be at least two additional people who are CPR-certified to assist the medical personnel of record for that competition.
2. Hunter and Jumper competitions using four or more rings simultaneously must have at least 2 Qualified Medical Personnel present during all performance sessions

FOR USEF- PARAMEDICS ARE NOT REQUIRED!- There are no requirements for equipment!

The FEI rules are a bit more stringent. - I didn’t have time to pull them

For some more context, Eventing Australia went through a massive tribunal hearing after two deaths approximately 10 years ago. And that tribunal came to the conclusion that medical personnel required was inadequate. AUS has since changed the requirements. BE (British Eventing) also has quite strict requirements.

When we went to re-write the rule, we mirrored what they had written.

It went through several committees and ultimately “stalled out” with the commentary that the organizers feared it would be cost prohibitive.

My clients and I never went back to the horse trials with the EMT with no gear…

Many riders and many organizers have no idea what coverage is required…

Kudos to the events who go above and beyond in what they provide.

I think people need to ask themselves, if I have a compound fracture do I want my first responder to be able to administer pain relief?
If, God Forbid I suffer an accident 45 mins from the nearest hospital on a rainy day (no helicopters), does my provider have the training and equipment to intubate me?

These are a few of the reasons that we don’t event any more… and the sole reason I stepped off the committee I was on.

We love the sport, but there is more that can be done.

Disclaimer- I have no idea what kind of medical coverage was at the AECs… I can only imagine and hope that they had all the excellent resources that the University of Kentucky has to offer.

[Tackpud]

The rule hit a road block when it was determined that the 50 states do not all have equal ideas on what first responders are and what they are called. Paramedics can only administer medications under a physicians order so if they are not working under a Dr office or hospital they are just the same as an EMT in many areas.

Paramedics are also not available in all areas that host shows, and cost prohibitive in many places. Not that I would not prefer to have one at a show were I riding, but the lack of agreement in committees made it impossible for the rule proposal to go farther.

[trubandloki]

In some areas, when you have a car accident and you are waiting for the emergency crews to show up, what you get is the local volunteer ambulance with a driver and an EMT.

It allows you to get to the hospital more quickly with their lights and sirens, and the hospital knows you are coming. But every day life does not offer what you want to require an event to have.

[grzywinskia]

Of course everyone is entitled to their opinions and I respect yours, I guess I just don’t see the comparison between something that you have to do like driving vs a luxury hobby like eventing

[grzywinskia]

When the rule made its way through the various committees we suggested that events that absolutely could not get access to our proposed medical staff would be allowed to apply for an exception but be required to put in the omnibus what they offered.

[trubandloki]

@grzywinskia

Of course everyone is entitled to their opinions and I respect yours, I guess I just don’t see the comparison between something that you have to do like driving vs a luxury hobby like eventing

I was pointing out that in a serious accident you do not even get an ambulance with a paramedic in some areas, because there are not ambulances with paramedics to be had. Using a car accident as an example.

In the other thread you tossed out that the local volunteer ambulance can do it, and I am tossing back that no, the local volunteer ambulance can’t do it, they do not have even have paramedics for emergency calls, let alone one that will sit at a horse show all day in all kinds of weather and no internet and bad cell coverage.

If you want to regulate something that is impossible in lots of places, so events can not happen, then go for it.

I feel like you live in a place in the world where it is easy to get a paramedic to stand by all day at something and are clearly not aware that this is not an option everywhere, it is not even an option where there is a life emergency not related to riding.

I think great medical coverage at events is a wonderful thing. I just do not like it when we regulate ourselves into a hole that makes it impossible for events to happen because people are not willing to look outside what they can do in their area.

You can not demand paramedics exist and are available. Sorry.

[grzywinskia]

For my own knowledge, can you give me an example of an event that runs at preliminary or above that is in an area where no ALS support is available?

[trubandloki]

@grzywinskia

For my own knowledge, can you give me an example of an event that runs at preliminary or above that is in an area where no ALS support is available?

I am sorry, I missed it in your first post that it has to be preliminary or above. I thought we were talking about all rated events.

Having advanced life support in the area and having paramedics that are available to sit at an event all day are two different things.

[tabula_rashah]

Not an eventer but I do participate in multiple high risk sports where I am in remote areas and there really isn’t much of any medical assistance there- basically do this at your own risk and know how to self-rescue. I’ve never really thought much about it one way or the other. I have been hurt pretty severely while showing- burst fracture of some vertebrae but I got up and drove myself to the hospital. So I guess, having qualified med people there would be a nice perk, it would never influence whether or not I do something.

[grzywinskia]

I’m just going to respectfully say we won’t agree on this matter and that’s totally fine- would love to hear from an event organizer who cannot find an ALS equipped service to provide medical coverage- again for my personal knowledge. And if they are interested, I can certainly help try and find someone for them. For some perspective the population of my “village” is 806 and my county is 22,500 and we have multiple agencies who would provide this service (volunteer departments for a donation or private ambulance services for a fee)

[PrairieRose]

Thank you for your advocacy on this. Response time can make all the difference.

[Snow_Mass]

Interesting discussion. States differ vastly for minimal requirements for athletic events.
I have a family member that competes in a high risk often remote access high mountain sport.
Care flight helicopter is on site for all international competitions. Being remote isn’t an excuse for less coverage - it means more coverage.
As a comp manager, you have an emergency plan on file w/the USEF but that’s the start.
Know the limitations of your on-site medical staff. Know the flight and drive dispatch time for flight and rolling emergency transport.
Know how far you are to your regional trauma center. This info then gets shared with your in-site medical staff so everyone is on the same safe-minded plan.

[RooTheDay]

Trauma is ultimately both a BLS skill and a surgical disease. There’s a reason why this study had the findings it did.

(Have there been improvements in the profession broadly since 1996? Sure, and a lot of them center around doing less for patients, rather than more. Remember the “science”, or lack thereof, around backboarding.)

[enjoytheride]

I’m a little confused as I’ve never been to a recognized HT in the US that does not have an ambulance on grounds the entire event.

The unrecognized events even have an EMT on grounds (no ambulance).

[trubandloki]

@enjoytheride

I’m a little confused as I’ve never been to a recognized HT in the US that does not have an ambulance on grounds the entire event.

Sorry that my post was not clear enough.

Of course there is an ambulance at recognized events. The point I was making is the OP insists on a paramedic, not an EMT. My experience is the ambulance typically has a driver and an EMT, not a paramedic.

@enjoytheride

I’m not sure where you live where an ambulance doesn’t show up for a car accident when needed? The few times I’ve been in a car accident I had to actively argue that I was fine and didn’t need transport. Every day activity is vastly different from sports events though.

@trubandloki

In some areas, when you have a car accident and you are waiting for the emergency crews to show up, what you get is the local volunteer ambulance with a driver and an EMT.

It allows you to get to the hospital more quickly with their lights and sirens, and the hospital knows you are coming. But every day life does not offer what you want to require an event to have.

@trubandloki

I was pointing out that in a serious accident you do not even get an ambulance with a paramedic in some areas, because there are not ambulances with paramedics to be had. Using a car accident as an example.

Again, sorry if my post was not clear.

Yes, an ambulance shows up (eventually). With the above mentioned driver and EMT, not always a paramedic. An EMT and a paramedic are not the same thing.

My point is that in some areas there are not lots of extra people educated to the level of being a paramedic or above that are available to hang out at a horse trial all day. An EMT is quite easy to get (most of the time).
Sometimes it is hard to find an ambulance available to sit at an event all day, or find one to replace the ambulance if it has to take someone for medical care.

[enjoytheride]

The USEA has a Safety Coordinator manual which covers some of this. In addition, I believe if there is only one ambulance on the grounds and it leaves, the event must pause until it returns.

For USEA and Safety Coordinator purposes, we use the following definitions for reference. Always check your
regional and state EMS systems to confirm that they define EMT/paramedic in the same way we do. There may
be some variances from state to state in what duties they are allowed to perform.
ADVANCED EMT/ PARAMEDIC This is the minimum standard for medical care at a USEA event. Paramedics
are trained in advanced trauma and cardiac life support, including starting IV fluids, administering medications
according to advanced life support protocols, intubation and airway management, as per their certifying state
or EMS region.
Paramedics are certified, not licensed by the state in which they work, because of this they do not operate
independently, except under specific protocols as laid out by the medical director of their service (a physician).
These are generally standard protocols throughout the country although there may be some variations. For
example, an unconscious person who has possibly sustained a head or neck injury triggers specific actions
that are designed to prevent a patient from further injury and to stabilize existing problems. In most states,
paramedics institute and carry out this care without having to talk directly to the physician who is their MEDICAL CONTROL (usually the Emergency Physician on duty at the closest facility and with whom they are in contact by radio). If they have questions or problems that may require deviation from protocol or further orders
they speak to MEDICAL CONTROL.
BASIC EMT In most states they can immobilize the patient and transport to the hospital. Although they make
great supplemental medical volunteers, a Basic EMT does not meet the minimum requirement for medical
coverage at an event. That must be the above-described EMT/Paramedic.

[grzywinskia]

Can you please reference in the rules where this is stated? I know for a fact that many events in the country are utilizing basic EMTs with no required equipment.

GR 847. 1.a - states EMT OR Paramedic

GR 847 2 - states an ambulance must be on site OR on call

[enjoytheride]

There is a Safety Coordinator manual

Safety Coordinator Manual

[grzywinskia]

Unless I am mistaken, nothing in the safety manual that you just shared prohibits EMT basics or requires an ambulance to be on site. If I am mistaken, please do point out the areas where it is stated also a safety coordinator manual will not supersede USEF regulations.

[enjoytheride]

I have never actually been to a recognized HT without an ambulance on grounds. Have you?